Surgical instrument guide device

ABSTRACT

An instrument guide device comprises an elongated guide shaft having proximal and distal ends and including an instrument lumen for receiving therethrough a manually operated instrument having an instrument shaft. A distal bendable member is disposed at the distal end of the guide shaft and a proximal bendable member is disposed at the proximal end of the guide shaft. Actuation means extends between the distal and proximal bendable members and provides a bending of the distal bendable member controlled from the proximal bendable member. The proximal bendable member is controlled from the manually operated instrument to cause a corresponding bending of said distal bendable member.

RELATED APPLICATIONS

The present application is a continuation of U.S. application Ser. No11/242,642, now issued as U.S. Pat. No. 7,842,028, filed on Oct. 3, 2005which claims priority to earlier filed U.S. Provisional Application60/700,776, filed on Jul. 20, 2005. The present invention also relatesto earlier filed U.S. application Ser. No. 10/822,081, now issued asU.S. Pat. No. 7,147,650, filed on Apr. 12, 2004 which, in turn, claimspriority to U.S. Provisional Application Ser. No. 60/515,560, filed onOct. 30, 2003, as well as U.S. application Ser. No. 11/185,911,nowissued as U.S. Pat. No. 7,686,826, filed on Jul. 20, 2005 which, inturn, claims priority to U.S. Provisional Application Ser. No.60/671,189, filed on Apr. 14, 2005. The content of all of theaforementioned applications are hereby incorporated by reference hereinin their entirety.

TECHNICAL FIELD

The present invention relates in general to surgical instruments, andmore particularly to manually-operated surgical instruments that areintended for use in minimally invasive surgery or other forms ofsurgical procedures or techniques. Even more particularly the presentinvention relates to a guide apparatus for a medical instrument. Theinstrument described herein may be used for laparoscopic procedures,however, it is to be understood that the instrument and guide of thepresent invention can be used for a wide variety of other procedures,including intraluminal procedures.

BACKGROUND OF THE INVENTION

Endoscopic and laparoscopic instruments currently available in themarket are extremely difficult to learn to operate and use, mainly dueto a lack of dexterity in their use. For instance, when using a typicallaparoscopic instrument during surgery, the orientation of the tool ofthe instrument is solely dictated by the locations of the target and theincision. These instruments generally function with a fulcrum effectusing the patients own incision area as the fulcrum. As a result, commontasks such as suturing, knotting and fine dissection have becomechallenging to master. Various laparoscopic instruments have beendeveloped over the years to overcome this deficiency, usually byproviding an extra articulation often controlled by a separatelydisposed control member for added control. However, even so theseinstruments still do not provide enough dexterity to allow the surgeonto perform common tasks such as suturing, particularly at anyarbitrarily selected orientation.

My above identified related earlier filed applications describe animproved instrument employing bendable section on the instrument itself.

An object of the present invention is to provide a guide device orapparatus that can be used with either conventional or the aboveidentified instruments for laparoscopic, endoscopic or other surgicalprocedures and that allows the surgeon to readily manipulate the tool orworking end of the surgical instrument with greater dexterity.

Another object of the present invention is to provide an improvedsurgical instrument and guide that has a wide variety of applications,including, but not limited to, through incisions, through natural bodyorifices or extending intraluminally.

SUMMARY OF THE INVENTION

To accomplish the foregoing and other objects, features and advantagesof this invention, there is provided an instrument guide device that iscomprised of an elongated guide shaft having proximal and distal endsand including an instrument lumen for receiving therethrough a manuallyoperated instrument having an instrument shaft and handle. A distalbendable member is disposed at the distal end of the guide shaft and aproximal bendable member id disposed at the proximal end of the guideshaft. Actuation means extends between the distal and proximal bendablemembers for providing a bending of the distal bendable member controlledfrom the proximal bendable member. The proximal bendable member iscontrolled from the manually operated instrument to cause acorresponding bending of the distal bendable member.

In accordance with other aspects of the present invention there isprovided an instrument guide device wherein the actuation means isconstructed and arranged so that a bending of the proximal bendablemember causes a like direction bending of the distal bendable member,or, alternatively, the actuation means is constructed and arranged sothat a bending of the proximal bendable member causes an oppositedirection bending of the distal bendable member. The proximal bendablemember is preferably moveable in any direction. A grip may be disposedbetween the proximal bendable member and the handle of the instrumentand constructed and arranged to have a passage through which theinstrument shaft extends. The grip may be formed as two pieces includinga grip portion and a rotation knob and the grip and knob portions aresupported for relative rotation therebetween. Means may be provided forsecuring the instrument handle to the grip. The bendable members mayeach comprise a unitary slotted structure having a plurality of discsseparated by slots. The guide shaft may be rigid, flexible or partiallyflexible. The instrument guide device may include a plurality ofproximal bendable members and a plurality of distal bendable members.The actuation means may comprise a plurality of cables that interconnectproximal and distal bendable members. The guide shaft may have at leasttwo lumens for respectively accommodating separate instrument shafts.The instrument that is inserted in the guide device may have instrumentproximal and distal bendable members.

In an other embodiment of the present invention there is provided asurgical instrument assembly that comprises an elongated instrumentshaft having proximal and distal ends, a working member coupled from thedistal end of the instrument shaft, a control handle disposed at theproximal end of the instrument shaft and a guide member for receivingthe instrument shaft. The guide member includes a guide shaft, a distalmotion means at the distal end of the guide shaft, a proximal motionmeans at the proximal end of the guide shaft and actuation meansextending between the distal and proximal motion means. The workingmember extends beyond a distal end of the guide shaft at an operativesite. Any deflection of the proximal motion means causes a correspondingdeflection of the distal motion means for control of the working member.

In accordance with still other aspects of the present invention there isprovided a surgical instrument assembly in which the distal motion meanscomprises a distal bendable member and the proximal motion meanscomprises a proximal bendable member that is moveable in any direction.A grip may be disposed between the proximal bendable member and thehandle of the instrument and constructed and arranged to have a passagethrough which the instrument shaft extends. The grip may be formed astwo pieces including a grip portion and a rotation knob and the grip andknob portions are supported for relative rotation therebetween. Theproximal bendable member may comprise a unitary slotted structure havinga plurality of discs separated by slots and further including aplurality of ribs interconnecting adjacent discs, the ribs beingdisposed at intervals about the member of less than 90 degrees.

In a further embodiment of the present invention there is provided asurgical instrument that is comprised of an elongated instrument shafthaving proximal and distal ends, a working member disposed at the distalend of the instrument shaft and a control handle disposed at theproximal end of the instrument shaft. The working member is coupled tothe distal end of the elongated instrument shaft via a distal motionmember. The control handle is coupled to the proximal end of theelongated instrument shaft via a proximal bendable member. Actuationmeans extends between the distal and proximal members whereby anydeflection of the control handle with respect to the elongatedinstrument shaft causes a corresponding bending of the distal motionmember for control of the working member. At least the proximal bendablemember comprises a unitary slotted structure having a plurality of discsseparated by slots.

In accordance with still other aspects of the present invention there isprovided an instrument guide device in which the distal motion memberalso comprises a bendable member formed as a unitary slotted structurehaving a plurality of discs separated by slots. The proximal bendablemember may include a plurality of ribs interconnecting adjacent discs,the ribs being disposed at intervals about the member of less than 90degrees. The ribs may be disposed at an interval on the order of 60degrees.

DESCRIPTION OF THE DRAWINGS

It should be understood that the drawings are provided for the purposeof illustration only and are not intended to define the limits of thedisclosure. The foregoing and other objects and advantages of theembodiments described herein will become apparent with reference to thefollowing detailed description when taken in conjunction with theaccompanying drawings, in which:

FIG. 1 is an exploded side view of a first embodiment of a surgicalinstrument and guide device using a rigid guide tube shaft;

FIG. 2 is a view of the proximal end of the guide device of FIG. 1, astaken along line 2-2 of FIG. 1;

FIG. 3 is a schematic side view of the instrument and guide assembly inuse as inserted through a patient's skin at an incision;

FIG. 4 is a fragmentary enlarged cross-sectional side view of theassembly of FIG. 3;

FIG. 5 is a cross-sectional view of the proximal bendable member, astaken along line 5-5 of FIG. 4;

FIG. 6 is an exploded perspective view of the guide apparatus or deviceillustrated in FIGS. 1-5;

FIG. 7 is a schematic cross-sectional side view illustrating the bendingaction of the assembly of FIG. 4;

FIG. 8 is a schematic cross-sectional side view illustrating analternate bending action;

FIG. 9 is a fragmentary cross-sectional side view similar to that shownin FIG. 4, but illustrating a second embodiment of the guide assemblyhaving an added rotational feature;

FIG. 10 is a schematic side view of the guide assembly of FIG. 9 in usewith the jaw end effector of FIG. 1;

FIG. 11 is a schematic side view of a third embodiment of the guideassembly or device employing a flexible main shaft on the guide device;

FIG. 12 is an exploded side view of a fourth embodiment of the guidedevice used with a second embodiment of a surgical instrument;

FIG. 13 is a view of the proximal end of the guide device of FIG. 12, astaken along line 13-13 of FIG. 12;

FIG. 14 is a schematic side view of the instrument and guide assembly ofFIG. 12 in use;

FIG. 15 is an exploded side view of a fifth embodiment of the guidedevice with a third embodiment of the surgical instrument;

FIG. 16 is a view of the proximal end of the guide device of FIG. 15, astaken 10 along line 16-16 of FIG. 15;

FIG. 17 is a schematic side view of the instrument and guide assembly ofFIG. 15 in use as inserted through a patient's skin at an incision;

FIG. 18 is an exploded side view of a sixth embodiment of the guidedevice and a fourth embodiment of the surgical instrument;

FIG. 19 is a schematic side view of the instrument and guide assembly ofFIG. 18 in use as inserted through a patient's skin at an incision;

FIG. 20 is an exploded side view of the fifth embodiment of the guidedevice as used with a fifth embodiment of the surgical instrument;

FIG. 21 is a schematic side view of the instrument and guide assembly ofFIG. 20 in use as inserted through a patient's skin at an incision;

FIG. 22 is an exploded side view of the sixth embodiment of the guidedevice as used with a sixth embodiment of the surgical instrument;

FIG. 23 is a schematic side view of the instrument and guide assembly ofFIG. 22 in use as inserted through a patient's skin at an incision;

FIG. 24 is a perspective view of another embodiment of the guide deviceuseable with two or more instruments; and

FIG. 25 is a side view of still another embodiment of the inventionusing multiple bendable members both proximally and distally on theguide member.

DETAILED DESCRIPTION

The instrument and guide member of the present invention may be used toperform minimally invasive procedures or virtually any other types ofsurgical or medical procedures. “Minimally invasive procedure” refersherein to a surgical procedure in which a surgeon operates through asmall cut or incision, the small incision being used to access theoperative site. In one embodiment, the incision length ranges from 1 mmto 20 mm in diameter, preferably from 5 mm to 10 mm in diameter. Thisprocedure contrasts those procedures requiring a large cut to access theoperative site. Thus, the instrument assembly is preferably used forinsertion through such small incisions and/or through a natural bodylumen or cavity, so as to locate the instrument at an internal targetsite for a particular surgical or medical procedure. The introduction ofthe surgical instrument assembly into the anatomy may also be bypercutaneous or surgical access to a lumen or vessel, or by introductionthrough a natural orifice in the anatomy. Also, even though theinstrument assembly is preferably used for MIS surgery it can also beused for open surgery or any other surgical or medical procedures.

In addition to use in a laparoscopic procedure, the instrument and guideof the present invention may be used in a variety of other medical orsurgical procedures including, but not limited to, colonoscopic, upperGI, arthroscopic, sinus, thorasic, transvaginal and cardiac procedures.Depending upon the particular procedure, the instrument shaft may berigid, semi-rigid or flexible.

Although reference is made herein to a surgical instrument and guide, itis contemplated that the principles of this invention also apply toother medical instruments, not necessarily for surgery, and including,but not limited to, such other implements as catheters, endoscopes,optics, as well as diagnostic and therapeutic instruments andimplements.

Still another aspect of the surgical guide instrument of the presentinvention is the ability to adapt the instrument and guide to a widevariety of medical procedure. This includes, but is not limited to,access to a body cavity such as through an incision or intraluminal usesuch as through a natural body aperture to a body lumen. Theintroduction of the instrument into the anatomy may also be bypercutaneous or surgical access to a lumen, cavity or vessel, or byintroduction through a natural orifice in the anatomy.

The concepts of the present invention relate to the use of a manuallycontrollable guide member or device through which either a conventionalinstrument shaft may be inserted or through which a novel instrument maybe inserted, such as the novel instrument described in my previouslyidentified related pending applications. With the use of the guidemember of the present invention, the user can insert the instrumentshaft through the guide member and then use the bendable members of theguide member to control the manipulation of the instrument. Thus, bydeflecting the instrument, once positioned in the guide member, thiscauses a deflection or bending at the proximal bendable member that istransferred to the distal bendable member (usually by cabling) tocontrol the positioning of the distal tool. This bending control at theguide member is preferably in all directions.

It should be noted that the amount of guide member bending motionproduced at the distal bending member is determined by the dimension ofthe proximal bendable member in comparison to that of the distalbendable member. In the disclosed embodiment the proximal bendablemember may be approximately three times the diameter of the distalbendable member, and as a result, the motion produced at the distalbendable member is about three times the magnitude of the motion at theproximal bendable member. Although FIG. 3 shows only the side view whereonly pitch motion is illustrated, it should be noted that the proximalbendable member can be bent in any and all directions controlling thedistal bendable member to bend in either the same or an oppositedirection, but in the same plane. As a result, as depicted in FIG. 3 thesurgeon is able to roll the instrument tool about its longitudinal axisat any orientation simply by a rolling action at the proximal bendablemember, controlled primarily by manipulation of the handle of theinserted instrument bearing against the guide member.

In this description reference is made to bendable members. These membersmay also be referred to as turnable members or flexible members. In thedescriptions set out herein, terms such as bendable section, bendablesegment, bendable motion member, or turnable member refer to an elementof the guide instrument that is controllably bendable in comparison toan element that is pivoted at a joint. The bendable elements of thepresent invention enable bending in any direction without anysingularity and that is further characterized by a ready capability tobend in any direction, all with a single unitary or uni-body structure.A definition of these bendable motion members is—a guide element, formedeither as a controlling means or a controlled means, and that is capableof being constrained by tension or compression forces to deviate from astraight line to a curved configuration without any sharp breaks orangularity.

The first embodiment is described in FIGS. 1-6. The guide member orinstrument has a proximal bendable member 20 and distal bendable member22 and receives the instrument 12 such as depicted in FIG. 3 in theinserted position of the instrument 12, depicted as the assembledinstrument system 14. The instrument 12 may be conventional and issecured in the guide member 10 so that motions at the instrument handle40 are essentially transferred through the guide member 10 to controlthe positioning of the end effector. In other words a deflection of thehandle 40 causes a bending of the proximal bendable member 20 (as inFIG. 3) which, in turn, bends the distal bendable member 22 to controlthe placement of the tool or end effector. This first embodiment alsoincludes a grip 16 that provides the interface between the handle 40 andthe proximal bendable member 20. The grip 16, in this particularembodiment, is one-piece so the only rotation of the instrument is byrotating the entire instrument and guide member. The instrument 12 islocked to the guide member 10 so there is no linear motion of theinstrument relative to the guide member.

Referring to FIG. 1, the surgical instrument 12 may be considered as ofconventional design and is comprised of a handle 40 at the proximal endof the instrument, an elongated flexible instrument shaft 36 and a toolor end effector 38 disposed at the distal end of the surgical instrument12. In the disclosed embodiment the instrument shaft 36 is preferablyconstructed so as to be at least partially flexible or bendable so as tosufficiently bend with the bending of the bendable members of the guidemember 10. The tool 38 is illustrated as including a fixed jaw 54 and amoveable jaw 52. The tool 38 is actuated by means of an actuation cable50 that extends through the instrument shaft 36 and is controlled fromthe slider 46 and return spring 48. A lever 42 operates the slider 46through the linkage or transfer bar 44. The closure of the lever 42pulls the cable 50 to close the jaws 52, 54.

In the drawings a set of jaws is depicted, however, other tools ordevices may be readily adapted for use with the instrument of thepresent invention. These include, but are not limited to, cameras,detectors, optics, scope, fluid delivery devices, syringes, etc. Thetool may include a variety of articulated tools such as jaws, scissors,graspers, needle holders, micro dissectors, staple appliers, tackers,suction irrigation tools and clip appliers. In addition, the tool mayinclude a non-articulated tool such as a cutting blade, probe,irrigator, catheter or suction orifice.

In FIGS. 1-6, the guide member or guide instrument 10 is depictedseparately from the surgical instrument 12 as in FIG. 1. In FIG. 3,there is shown the assembled system 14 with the instrument having beeninserted into and through the guide member 10. In FIG. 3 note that theguide member shaft 18 extends through the cannula 8 at the insertionsite 6 of the patient's skin 4. The end effector or tool 38 is disclosedin FIG. 3 as extending from the distal bendable member 22. FIG. 3 alsoshows a protective sheath 24 that may extend about the distal flexmember 22.

The guide member 10, in addition to including the guide shaft 18, alsoincludes the proximal flexible or bendable member 20 and the distalflexible or bendable member 22. An adaptor cover 26 is disposed about aportion of the proximal bendable member 20. The adaptor cover 26includes a funnel or conical-shaped portion 96 (see FIG. 6) forreceiving ends of the proximal bendable member 20 and the guide shaft18. The grip 16 of the guide member 10 receives the other end of theproximal bendable member 20. The grip 16 is preferably a single piecestructure having a cavity 28 for receiving the boss 30 of theconventional instrument 12. The boss 30 may also be provided with arecess 32 for receiving a locking screw 34 that extends through the grip16 into the cavity 28 and into the recess 32. The use of the lockingscrew 34 secures the instrument 12 within the guide member 10. Motionsof the instrument are thus directly transferred to the grip 16 and, inturn, to the proximal bendable member 20. The length of the guide memberis selected so that the instrument tool extends beyond the end of theguide member, as depicted in FIG. 3.

This first embodiment also discloses the details of the proximal anddistal bendable members 20 and 22, particularly in FIGS. 4-6. Bendablemember 20 has a central passage 56 through which the instrument shaft 36can extend. FIG. 4 also illustrates the lumen 58 defined by the guideshaft 18 with the instrument shaft 36 extending therethrough. Similarly,the distal bendable member 22 includes a passage 60 for receiving theinstrument shaft 36. In FIG. 4 the guide shaft 18 is shown as rigid, butcould also be partially rigid or flexible. The guide shaft 18 may bemade of a light weight metal material or of plastic.

The grip 16 includes a cavity 62 (see FIG. 6) for receiving one end ofthe proximal bendable member 20. This bendable member 20 is seated atthe end wall 64 of the grip 16. The wall 64 has a tapered or conicalpassage 66 for receiving the instrument shaft 36.

As depicted in FIG. 6, there are also provided several passages 68 forcabling. The grip 16 also includes a cavity 70 for the anchors 86 andsprings 88. This includes a plurality of proximal anchors 86 and relatedsprings 88. The springs 88 are for tensioning the associated cables76-82. The distal bendable member 22 includes an extending end 94 forreceiving the distal anchors 84 that secure the distal ends of theactuation cables 76-82.

The grip 16 also preferably includes a raised lip 72 that is useful ingrasping the guide grip 16. The raised lip 72 preferably has spacedfinger grooves 74.

The control between the proximal and distal bendable members is carriedout primarily by means of a set of cables that extend between thesebendable members. A bending at the proximal bendable member causes apulling of one or more cables while there is a relaxing of other opposedcables causing a corresponding bending action at the distal bendablemember. The cabling that is used includes flexible cables 76, 78, 80 and82 that extend between the proximal and distal bendable members. Aplurality of distal anchors 84 are used at the distal end of thecabling. Cable passages 90 are provided in the proximal bendable member20, and cable passages 92 are provided in the distal bendable member 22.The passages 90 and 92 accommodate these cables. Also, guide discs (notshown) may be provided along the cables, particularly within the guideshaft 18 so assure that the cables are maintained in position as theyextend from one end of the guide shaft to the other end.

The proximal bendable member 20 is comprised of a series of adjacentdiscs 98 that define therebetween spaces or slots 100. Connecting ribs102 extend between adjacent discs 98. FIG. 5 depicts the location of theribs 102. In a similar manner, the distal bendable member 22 includes aseries of discs 104 that define therebetween slots or spaces 106. Ribs108 extend between adjacent discs 104. For further details of thebendable members and the preferred relationship between the disks, slotsand ribs, refer to application Ser. No. 11/185,911, filed on Jul. 20,2005, the content of which is hereby incorporated by reference herein.

FIGS. 7 and 8 depict the guide member with the instrument insertedtherein and also depicts the various motions that occur depending uponthe position of the control cables that control the bending actions. InFIG. 7, a downward movement of the proximal bendable member 20 causes anupward movement of the distal bendable member 22. Alternatively, in FIG.8 a downward movement of the proximal bendable member 20 causes adownward movement of the distal bendable member 22. This all occurs byvirtue of the cabling being either extended or retracted as the proximalbendable member is manipulated. The different direction bending comesabout by either having the cabling straight, as in FIG. 7 or crossed 180degrees, as in FIG. 8. In FIGS. 7 and 8, the instrument handle is shownfixed to the grip portion 16, and by manipulating of the handle, thiscauses a direct manipulation of the grip portion, which, in turn,controls the bending at the proximal bendable member. The bending at theproximal bendable member, in turn, controls the positioning of thedistal bendable member and end effector.

A second embodiment of the present invention is shown in FIGS. 9 and 10.This uses a two-piece grip 116 with a rotation knob 112. This embodimentallows the same bending action as in the first embodiment via proximaland distal bendable members, but additionally allows the user to rotatethe guide member relative to the grip portion 116. This rotation actioncauses rotation of the bendable members 20, 22 and guide shaft 36 ontheir axes.

The embodiment of FIGS. 9 and 10 also illustrates the instrument handlebeing fixedly supported to the grip 116. In this particular embodiment,rather than a single-piece grip, there is provided an essentiallytwo-piece grip that also includes the rotation knob 112. A boss 114 isprovided on the knob 112 terminating in an end wall 118 of the rotationknob 112. The grip 116 is provided with a cavity 120 for receiving theboss 114. Retention means 122 (annular inwardly extending rib) extendsfrom the grip 116 into an annular slot. In this way the rotation knob112 is engaged with the grip 116 but is freely rotatable relative to thegrip 116. FIG. 10 also shows the arrow 111 indicating rotation of theinstrument handle 12 relative to the knob 112. Arrow 113 indicates thecorresponding rotation at the end effector 38. Even though the item 112is referred to as a rotation knob, it is understood that the knob 112can be held non-rotatable while the grip 116 is rotated relativethereto, such as depicted by the arrows 111, 113 in FIG. 10.

In the first two embodiments of the invention described in FIGS. 1-10,the guide shaft itself may be rigid, flexible or semi-rigid, but isbasically depicted as rigid. The instrument shaft itself is preferablyat least partially flexible so that it can flex as the proximal enddistal members are operated.

A third embodiment of the present invention is shown in FIG. 11illustrating a flexible or partially flexible guide shaft or tube 126.In the first two embodiments the guide shafts can be rigid or partiallyflexible and the instrument shaft should be at least partially flexibleso as to flex when the bendable members are in action. The embodimentillustrated in FIG. 11 is meant to use a flexible or semi-flexible guidetube 126. This is illustrated as being placed through a cannula 8 at aninsertion site 6 of the patient's skin 4, such as for laparoscopic use.FIG. 11 also schematically illustrates the instrument handle 12, thegrip and the proximal and distal bendable members 20 and 22. Other thanthe guide shaft 126, the rest of the guide member may be substantiallyidentical to that described in either FIG. 1-8 or 9 and 10. Thisparticular embodiment also lends itself to use of the instrument andguide assembly intraluminally, such a through an incision or naturalbody orifice. The end effector may be located in the lumen or theinstrument may be positioned so that the end effector is either locatedin a body cavity or extends through a body lumen or vessel to a cavity.

This third embodiment may also accommodate a conventional endoscopewithin the guide member. The endoscope is inserted in the guide member.Such an endoscope may have channels for instrumentation, for optics orfor other purposes such as irrigation. In that case, the guide member ofthe present invention can be used for steering the endoscope. This maybe quite useful, particularly for intraluminal applications, wherein theendoscope is required to navigate tight curvatures in the anatomiclumen.

A fourth embodiment is shown in FIGS. 12-14 using a one-piece grip thatallows the guide member to be rotatable relative to the instrumenthandle. FIG. 12 is an exploded side view of this fourth embodiment ofthe guide device used with a second embodiment of a surgical instrument,namely one that includes an interlock between the instrument and guidemember. FIG. 13 is a view of the proximal end of the guide device ofFIG. 12, as taken along line 13-13 of FIG. 12. FIG. 14 is a schematicside view of the instrument and guide assembly of FIG. 12 in use throughan incision. The embodiment of FIGS. 12-14 may be considered as a quickdisconnect via the use of a catch that readily enables the instrument tobe connected and disconnected with the guide member.

As shown in FIG. 14 rotation can occur of either the handle or grip. Theembodiment depicted in FIGS. 12-14 uses a one-piece grip 130 having atone end a raised lip 132 with a catch 133 that extends into the cavity134. The grip 130 may be substantially the same as the grip depicted inFIGS. 1-6. The boss 138 on the handle 40 has an annular groove 139. Thecatch 133 is engaged within the annular groove 139 once the instrumentis inserted into the guide member 128. In the embodiment of FIGS. 12-14,the guide member 128 is connected with the instrument in a manner wherethe guide member 128 can be rotated relative to the instrument or viceversa. This occurs by virtue of the catch 133 being readily rotatablewithin the groove 139 of the instrument handle. In essence, either thegrip 130 can be rotated to rotate the entire guide member or the handleof the instrument itself can be rotated. These two different rotationsare illustrated by separate arrows 121, 123 in FIG. 14 and correspondingarrows 125, 127 at the distal end of the instrument. The rotation arrow121 associated with the handle controls the rotation depicted by thedistal arrow 127. The rotation arrow 123 associated with the gripcontrols the rotation depicted by the distal arrow 125.

In FIG. 14 note that the guide member shaft 18 extends through thecannula 8 at the insertion site 6 of the patient's skin 4. The endeffector or tool 38 is disclosed in FIG. 14 as extending from the distalbendable member 22. A protective sheath may extend about the distal flexmember 22.

A locking device or mechanism may also be associated with the instrumentassembly of FIG. 14 in which case the cabling between the proximal anddistal bendable members 20, 22 is pinched off holding the bendablemembers in a fixed bendable orientation. Refer to co-pending applicationSer. No. 10/822,081, filed Apr. 12, 2004, which is hereby incorporatedby reference in its entirety, for an illustration of a lockingmechanism, particularly set forth in FIG. 27. This is described aslocking the cables in a particular position so that the orientation ofthe bendable members are fixed. With this arrangement if the guidemember is rotated with the members 20, 22 bent then there is a rotationof the curved distal bendable member, thus displacing the end effectorand providing an additional degree of control thereof. This additionaldegree of control can be provided with several of the embodimentsdescribed in this application. Rotation of the instrument itself rotatesthe end effector within the guide member.

A fifth embodiment is shown in FIGS. 15-17 in which the guide memberoperates as before, but the additional feature is the support of theinstrument that allows a sliding action of the instrument within theguide member, as well as a rotation of the instrument. When theinstrument is engaged with the guide member the bending motions can betransferred as in earlier embodiments. In addition the user can move theinstrument linearly in and out within the guide member, and can rotatethe instrument within the guide member. This embodiment is, inparticular, advantageous for intraluminal use of the instrument assemblywhere is may be desirable to have the capability to linearly move theinstrument within a body lumen.

FIG. 15 is an exploded side view of the fifth embodiment of the guidedevice with a third embodiment of the surgical instrument. FIG. 16 is aview of the proximal end of the guide device of FIG. 15, as taken alongline 16-16 of FIG. 15. FIG. 17 is a schematic side view of theinstrument and guide assembly of FIG. 15 in use as inserted through apatient's skin at an incision. As mentioned before the instrumentassembly may also be used intraluminally in which case the instrumentand guide shafts are both flexible along their respective lengths.

In the embodiment of FIGS. 15-17, it is noted that the grip 142 hasassociated therewith a rotational knob 144. The grip and rotational knobmay be supported such as in the manner previously described in FIG. 4.In the illustrated embodiment the grip portion and rotation knob arepreferably one-piece. The grip portion 142 includes an end wall 146 anda tapered passage 148 for receiving the instrument shaft 36. The veryproximal end 141 of the shaft 36 may be seated in the tapered passage148. Because the surgical instrument itself is not secured into thegrip, it is possible to move the surgical instrument linearly such as inthe direction of the arrow 145 in FIG. 17 to provide the correspondinglinear translation of the end effector as in the direction of arrow 147illustrated in FIG. 17. In addition to this linear movement, there is,of course, also bending action as occurs in previous embodiments betweenthe proximal and distal bendable members of the guide tube.

In the embodiment of FIGS. 15-17, the instrument is also capable ofbeing rotated. Arrows in FIG. 17 indicate rotation of the handle anddeflection of the proximal bendable member. Corresponding arrowsindicate motion at the distal end of the instrument assembly. Arrow 151indicates a bending at the proximal bendable member 20 and arrow 153indicates a corresponding bending at the distal bendable member 22.Arrow 155 indicates a rotation at the instrument handle and arrow 157indicates a corresponding rotation at the end effector. In FIG. 17 theinstrument shaft is shown with a certain length, but it is understoodthat the length thereof may vary depending upon the particular medicaluse.

FIG. 18 is an exploded side view of a sixth embodiment of the guidedevice and a fourth embodiment of the surgical instrument. FIG. 19 is aschematic side view of the instrument and guide assembly of FIG. 18 inuse as inserted through a patient's skin at an incision. The sixthembodiment shown in FIGS. 18 and 19 uses a one-piece grip including gripportion 142 and knob portion 144. The instrument itself has a rotationknob 156 with a boss 158 that extends within a cavity 160 of the handle40. FIG. 18 also illustrates the instrument shaft 162. An end effector38 is also illustrated at the very distal end of the instrument shaft. Apush-pull cable 164 extends through the instrument shaft 162 and issecured at a rotational barrel 166 within the slider 168. End effectoractuation occurs via the lever 167.

The view of FIG. 19 illustrates the instrument having been inserted intothe guide member. At the proximal end of the assembly, there areprovided one bendable member 20 of the guide member, a rotation knob andgrip on the guide member and and a rotation knob 156 of the instrumenthandle. At the distal end of the instrument, there is provided distalbendable member 22 of the guide member. The embodiment of FIGS. 18 and19 allows bending at the proximal bendable member and also allowsrotation at the knob 156. The catch 176 in the annular slot 172 ofcoupler 170 prevents any linear translation of the instrument relativeto the guide member but permits relative rotation of the instrumenthandle. The 170 is adapted to fit within the cinical cavity 174 of theguide member.

In the embodiment of FIGS. 18 and 19 there are several degrees of motionthat are possibly due to the bendable members that are used and therotations that are possible. Some of these motion are illustrated inFIG. 19 by means of corresponding arrows. Arrow 171 indicates a rotationof the instrument and arrow 173 indicates a corresponding rotation atthe instrument end effector. Arrow 175 indicates a rotation of the guidemember at the grip 142 and arrow 177 indicates a corresponding rotationat the distal end of the guide member. Arrow 179 indicates a bending atthe bendable section 20 and arrow 181 indicates a corresponding bendingat the distal bendable member 22.

Reference is now made to related application Ser. Nos. 10/822,081 filedApr. 12, 2004 and 11/185,911 filed Jul. 20, 2005 which are herebyincorporated by reference herein and considered as a part of thedisclosure in the instant application. The subject matter of theseapplications incorporates proximal and distal bendable members withinthe instrument itself. An instrument of this type can also be used inassociation with the guide member of the present invention that alsoincludes proximal and distal bendable sections or members. Embodimentsare now described that incorporate bendable members in both theinstrument and guide member.

A seventh embodiment is shown in FIGS. 20 and 21. This embodimentemploys a non-conventional instrument such as the instrument describedin co-pending application Ser. No. 11/185,911, filed Jul. 20, 2005 whichuses proximal and distal bendable sections of the instrument. Thus, thecombined assembly actually has two proximal bendable members and twodistal bendable members so as to provide greater degrees of control ofthe end effector. There is a proximal bendable member on the guidemember and one on the instrument itself. There is a distal bendablemember on the guide member and one on the instrument itself.

FIG. 20 is an exploded side view of the fifth embodiment of the guidedevice as used with a fifth embodiment of the surgical instrument. FIG.21 is a schematic side view of the instrument and guide assembly of FIG.20 in use as inserted through a patient's skin at an incision. Theembodiment of FIGS. 20 and 21 differs from the embodiment of FIGS. 18and 19 primarily in that it has the ability to linearly translate theinstrument within the guide member. FIG. 21 shows the various motions ofthe assembly as illustrated by the arrows.

Accordingly, in the embodiment of FIGS. 20 and 21 there is provided aninstrument that has a rotation knob 182 with a boss 184 that extendswithin a cavity 186 of the handle 40. FIG. 20 also illustrates theinstrument shaft 162, the proximal bendable member 188 and the distalbendable member 190. An end effector 38 is also illustrated at the verydistal end of the instrument shaft. A push-pull cable 164 extendsthrough the instrument shaft 162 and is secured at a rotational barrel166 within the slider 168. For further details of the instrumentdescribed in FIG. 20, refer to application Ser. Nos. 10/822,081 and11/185,911 and, in particular, FIG. 8 of Ser. No. 11/185,911.

The embodiment in FIGS. 20 and 21 also includes the grip portion 142 andthe rotation knob 144 that have been described previously in connectionwith FIGS. 15-17. In FIG. 20 the guide member 140 also includes proximalbendable member 20, distal bendable member 22 and guide shaft 18. Thecoupler 26 connects the proximal bendable member with the guide shaft.

The view of FIG. 21 illustrates the instrument having been inserted intothe guide member. At the proximal end of the assembly, there areprovided two bendable members, namely, proximal bendable members 20 and188, associated, respectively, with the grip 142 and the instrumenthandle 40. At the distal end of the instrument, there are provideddistal bendable members 22 and 190 associated, respectively, with theguide shaft 18 and the instrument shaft 162. The version of FIG. 21 alsocan provide linear translation of the instrument within the guide. Thearrows in FIG. 21 show the various motions.

In the embodiment of FIGS. 20 and 21 there are several degrees of motionthat are possibly due to the several bendable members that are used andthe rotations that are possible. Some of these motion are illustrated inFIG. 21 by means of corresponding arrows. Arrow 171 indicates a rotationof the instrument at the knob 182 and arrow 173 indicates acorresponding rotation at the instrument end effector. Arrow 175indicates a rotation of the guide member at the grip 142 and arrow 177indicates a corresponding rotation at the distal end of the guidemember. Arrow 179 indicates a bending at the bendable section 20 andarrow 181 indicates a corresponding bending at the distal bendablemember 22. Arrow 183 indicates a bending at the bendable section 188 andarrow 185 indicates a corresponding bending at the distal bendablemember 190.

An eighth embodiment of the invention is illustrated in FIGS. 22 and 23.This embodiment is quite similar to the embodiment illustrated in FIGS.20 and 21 in that it uses the two pairs of cooperating bendablesections, one pair on the instrument and the other pair on the guidemember. However, in this embodiment a one-piece grip portion is employedwith a catch 176 for securing the instrument within the grip portion,while allowing rotation, but no linear translation. Refer to FIGS. 12-14for further details of the grip portion of the guide member.

FIG. 22 is an exploded side view of the sixth embodiment of the guidedevice as used with a sixth embodiment of the surgical instrument. FIG.23 is a schematic side view of the instrument and guide assembly of FIG.22 in use as inserted through a patient's skin at an incision. In FIG.22 the guide member 142 has a conical cavity 174 into which the catch176 can extend for engagement with the instrument body. This engagementallows relative rotation but not linear translation.

Accordingly, in the embodiment of FIGS. 22 and 23 there is provided aninstrument 194 that has a rotation knob 182 with a boss 184 that extendswithin a cavity 186 of the handle 40. FIG. 22 also illustrates theinstrument shaft 162, the proximal bendable member 188 and the distalbendable member 190. An end effector 38 is also illustrated at the verydistal end of the instrument shaft. A push-pull cable 164 extendsthrough the instrument shaft 162 and is secured at a rotational barrel166 within the slider 168. For further details of the instrumentdescribed in FIG. 22, refer to application Ser. Nos. 10/822,081 and11/185,911 and, in particular, FIG. 8 of Ser. No. 11/185,911.

The embodiment in FIGS. 22 and 23 also includes an instrument having acover or coupler 192 that connects the proximal bendable member 188 withthe guide shaft 162. The coupler 192 has an annular groove 196 that isadapted to receive the free end of the catch 176. This catch and groovearrangement allows rotation between the instrument and the guide member.The conical surface of the coupler 192 mates with the conical shapedcavity 174 in the grip 142. FIG. 23 shows the instrument fully andoperably engaged with the guide member.

In the embodiment of FIGS. 22 and 23 there are several degrees of motionthat are possibly due to the several bendable members that are used andthe rotations that are possible. Some of these motion are illustrated inFIG. 23 by means of corresponding arrows. Arrow 171 indicates a rotationof the instrument at the knob 182 and arrow 173 indicates acorresponding rotation at the instrument end effector. Arrow 175indicates a rotation of the guide member at the grip 142 and arrow 177indicates a corresponding rotation at the distal end of the guidemember. Arrow 179 indicates a bending at the bendable section 20 andarrow 181 indicates a corresponding bending at the distal bendablemember 22. Arrow 183 indicates a bending at the bendable section 188 andarrow 185 indicates a corresponding bending at the distal bendablemember 190.

A ninth embodiment of the present invention is shown in FIG. 24 in whichthe guide member accommodates multiple instruments as well as otherpossible instrumentation. Any of the various instruments that have beenpreviously illustrated may be used in this embodiment. FIG. 24 shows achannel that may be used, for example, for irrigation purposes or foroptics. FIG. 24 is an embodiment in which the guide shaft has multiplechannels for receiving multiple instruments or other devices and may beeither flexible, rigid or semi-flexible. FIG. 24 shows a connector 216coupled to a proximal end of a catheter or other tubular device 214 thatcan be used either for optics or for other purposes. The tube 214extends through one of the lumens within the guide member 200. Both ofthe instruments illustrated in FIG. 24 may be considered as of the sametype as previously described in either FIG. 20 or 22. Each of theseinstruments is illustrated as controlling a respective end effector 38.

In the embodiment of FIG. 24 there is provided a one-piece grip 202having a raised lip 204 that may be grasped by the user. In an alternateembodiment a two-piece grip may be used. The guide member has a proximalbendable member 206 and a distal bendable member 208. Cabling connectsbetween these bendable members in the same manner as previouslydescribed with guide members having only one lumen. The guide member 200may be considered as having three separate lumens; two lumens 210accommodate the respective instruments 180 and one lumen 212 is forreceiving the catheter, tube or shaft 214. In this embodiment becausethe instruments have been described before there is no detaileddescription herein. Refer to FIGS. 19-23. Each of the instrumentsincludes a proximal bendable section 188 and a distal bendable section190. Each also includes a control knob 182.

In the embodiment of FIG. 24 there are several degrees of motion thatare possible due to the several bendable members that are used and therotations that are possible. Some of these motion are illustrated inFIG. 24 by means of corresponding arrows. Arrow 171 indicates a rotationof the instrument at the knob 182 and arrow 173 indicates acorresponding rotation at the instrument end effector. Arrow 175indicates a rotation of the guide member at the grip 142 and arrow 177indicates a corresponding rotation at the distal end of the guidemember. Arrow 179 indicates a bending at the bendable section 20 andarrow 181 indicates a corresponding bending at the distal bendablemember 22.

Arrow 183 indicates a bending at the bendable section 188 and arrow 185indicates a corresponding bending at the distal bendable member 190.

Reference is now made to a further embodiment of the present inventionillustrated in FIG. 25 in which the guide member accepts one or moreinstruments, but instead of having a single bendable member on each endof the guide shaft there are two or more bendable members or sections oneach end. A first proximal bendable member controls a first distalbendable member and a second proximal bendable member controls a seconddistal bendable member. The control is by means of first cabling thatextends between the respective first bendable members and separatesecond cabling that extends between the respective second bendablemembers. In this way, an instrument inserted in the guide member hasenhanced control by virtue of added degrees of control with the multipleproximal bendable members controlling respective multiple distalbendable members.

FIG. 25 shows an instrument guide member that incorporates the multiplebendable member concepts. This guide member 220 may be similar to thatdescribed previously in FIG. 1 but includes multiple bendable sectionsat both ends of the guide member. Although only two bendable members areillustrated at each end of the guide member, it is understood that morethan two may be incorporated in the guide device 220. The guide member220 may receive an instrument such as the instrument disclosed in FIG.1, but can also receive other instrument designs such as other onesdisclosed herein or in the related application mentioned herein. Theparticular instrument of FIG. 1 locks to the grip portion 222 of theguide member 220 by means of the locking screw 224. An end effector (notshown) extends from the very distal end of the guide member 220 when theinstrument is fully inserted in the guide member. The guide of FIG. 25may also accommodate multiple instruments, as in FIG. 24.

In FIG. 25, the guide member or guide instrument 220 is depictedseparately from the surgical instrument as in FIG. 1. The assembledsystem has the instrument inserted into and through the guide member220. The guide member 220 includes a guide shaft 226 that may extendthrough a cannula at an insertion site of the patient disposing theproximal bendable members outside the patient and the distal bendablemembers within the patient adjacent the operative site. The end effectoror tool extends from the very distal end of the guide member. Aprotective sheath may extend about one or both of the distal flexible orbendable members.

The guide member 220, in addition to including the guide shaft 226, alsoincludes a first proximal flexible or bendable member 228A and a secondproximal flexible or bendable member 228B. An adaptor cover 232 isdisposed about a portion of the proximal bendable member 228B. Theadaptor cover 232 includes a funnel or conical-shaped portion or cavity234 (see cavity 96 in FIG. 6) for respectively receiving ends of theproximal bendable member 228B and the guide shaft 226. The more proximalend of the proximal bendable member 228B is held in an intermediatemember 236 that may be of various lengths depending upon the particularmedical application. The intermediate section 236 may be rigid, flexibleor semi-flexible, but is preferably rigid. The intermediate member 236also holds the more distal end of the proximal bendable member 228A. Thebendable members 228A and 228B are thus separately mounted and can beseparately controlled from the instrument handle actions.

The grip 222 of the guide member 220 receives the other end of theproximal bendable member 228A. The grip 222 is preferably a single piecestructure having a cavity 238 for receiving the boss of the instrument,as depicted in FIG. 1. The boss may also be provided with a recess forreceiving the locking screw 224 that extends through the grip 222 intothe cavity 238 and into the recess in the instrument. The use of thelocking screw 224 secures the instrument within the guide member 222.Motions of the instrument are thus directly transferred to the grip 222and both of the proximal bendable members. The length of the guidemember is selected so that the instrument tool extends beyond the end ofthe guide member, as depicted in FIG. 3.

The embodiment of FIG. 25 also discloses the details of the proximal anddistal bendable members 228 and 230. Each of the members may beconstructed as illustrated before in FIGS. 4-6. All of these bendablemember have a central passage through which the instrument shaft canextend. FIG. 25 also illustrates the lumen 240 defined by the guideshaft 226 with the instrument shaft extendable therethrough. Similarly,the distal bendable members include a centrally disposed passage forreceiving the more distal end of the instrument shaft. In FIG. 25 theguide shaft 226 is shown as rigid, but could also be partially flexibleor flexible. The guide shaft 226 may be made of a light weight metalmaterial or of plastic.

The grip 222 includes a cavity (see FIG. 6) for receiving one end of theproximal bendable member 228A. The grip 222 also preferably includes araised lip that is useful in grasping the guide grip 222. The raised lippreferably has spaced finger grooves. This bendable member 228A isseated at an end wall of the grip 222. This end wall may have a taperedor conical passage for receiving the instrument shaft. As depicted inFIG. 6, there are also provided several passages for cabling. The grip222 may also include a cavity for anchors and springs, as depicted inthe first embodiment described herein. This includes a plurality ofproximal anchors and related springs. The springs are for tensioning theassociated cables. For the proximal bendable member 228B the anchors andsprings may be disposed in the intermediate member 236. Cablingassociated with the proximal bendable member 228A passes through theintermediate member 236.

The guide member 220, at the distal end thereof, includes a pair ofspacedly disposed distal bendable members 230A and 230B separated by theintermediate member 244. The distal bendable members 230A and 230B mayinclude an extending end 242 for receiving distal anchors that securethe distal ends of the actuation cables. The actuation cables associatedwith the distal bendable member 230A may be disposed in the intermediatesection 244 between the distal bendable members 230A, 230B. The controlbetween the proximal and distal bendable members is carried outprimarily by means of a set of cables that extend between these bendablemembers. A bending at the proximal bendable member causes a pulling ofone or more cables while there is a relaxing of other opposed cablescausing a corresponding bending action at the distal bendable member.The cabling may be provided in either the arrangement of FIG. 7 or ofFIG. 8, depending on the desired direction of bending.

The cabling that is used includes flexible cables that extend betweenthe proximal and distal bendable members. Refer to FIG. 1. A pluralityof distal anchors are used at each end of the cabling. Cable passagesare provided in the proximal bendable members and the distal bendablemembers. The passages accommodate these cables. Also, guide discs (notshown) may be provided along the cables, particularly within the guideshaft so as to assure that the cables are maintained in position as theyextend from one end of the guide shaft to the other end.

The proximal bendable members are each comprised of a series of adjacentdiscs that define therebetween spaces or slots, as in FIGS. 4-6.Connecting ribs extend between adjacent discs. FIG. 5 depicts thelocation of the ribs. In a similar manner, the distal bendable memberseach include a series of discs that define therebetween slots or spaces.Ribs extend between adjacent discs. For further details of the bendablemembers and the preferred relationship between the disks, slots andribs, refer to application Ser. No. 11/185,911, filed on Jul. 20, 2005,the content of which is hereby incorporated by reference herein.

Now, in the embodiment of FIG. 25 the cabling is preferably connected sothat there are four cables between the proximal bendable member 228A andthe distal bendable member 230B, and likewise there are four cablesbetween the proximal bendable member 228B and the distal bendable member230A. In an alternate arrangement the cabling from the proximal bendablemember 228A may control the distal bendable member 230A and the cablingfrom the proximal bendable member 228B may control the distal bendablemember 230B. Also, fewer or greater numbers of cables may be used forcontrol between the proximal and distal bendable members.

The user of the instrument system may grasp the instrument handle,engage the instrument with the guide, as in FIG. 3 and manipulate theguide member essentially by manipulating the instrument handle which issecured to the guide grip 222. A deflection, for example, of theproximal bendable member 228A causes the cables to be tensioned andrelaxed so as to cause the distal bendable member 230B to becorrespondingly deflected. This deflection may be in the same directionor in opposed directions. See FIGS. 7 and 8. Similarly, a deflection ofthe proximal bendable member 228B causes the cables to be tensioned andrelaxed so as to cause the distal bendable member 230A to becorrespondingly deflected.

Having now described one embodiment of the present invention, it shouldnow be apparent to those skilled in the art that numerous otherembodiments and modifications thereof are contemplated as falling withinthe scope of the present invention as defined by the appended claims.

What is claimed is:
 1. A surgical instrument comprising: an elongatedinstrument shaft having proximal and distal ends; an end effectorcoupled from the distal end of the instrument shaft; a control handledisposed at the proximal end of the instrument shaft; said elongatedinstrument shaft, end effector and control handle defining a manuallyoperated instrument having inserted and withdrawn positions; a guidemember for receiving the manually operated instrument and including; aguide shaft having respective proximal and distal ends; a distalbendable member at the distal end of said guide shaft and having atleast a distal end; a proximal articulatable member at the proximal endof said guide shaft and having a proximal end and a distal end; anadaptor coupled between the distal end of proximal articulatable memberand the proximal end of the guide shaft; said adaptor receiving andsupporting the distal end of the proximal articulatable member; a grip,separate from the manually operated instrument, receiving and supportingthe proximal end of the proximal articulatable member; a lumen throughwhich the manually operated instrument is inserted distally through atleast the grip, proximal articulatable member, guide shaft and distalbendable member; said lumen terminating at a distal port at the distalend of the distal bendable member and at a proximal port at the grip;and actuation means extending between said distal bendable member andsaid proximal articulatable member; said end effector extending from thedistal port of the lumen at an operative site and the control handleextending from the proximal port of the lumen when the manually operatedinstrument is inserted through the lumen; whereby any deflection of saidproximal articulatable member caused by manipulation of said manuallyoperated instrument causes a corresponding deflection of said distalbendable member for control of said distal bendable member, and in turn,said end effector.
 2. The instrument of claim 1 wherein said actuationmeans is constructed and arranged so that a bending of the proximalarticulatable member causes one of an opposite and a like directionbending of the distal bendable member.
 3. The instrument of claim 1wherein the proximal articulatable member is a proximal bendable member,the instrument lumen also extends through both said distal and proximalbendable members, and the proximal bendable member is controlled fromthe manually operated instrument to, not only cause a correspondingbending of the distal bendable member, but also to cause are-positioning of the end effector of the manually operated instrument.4. The instrument of claim 1 wherein said proximal articulatable memberis moveable in any direction.
 5. The instrument of claim 1 wherein theproximal articulatable member has a maximum transverse cross-sectionaldimension that is greater than a maximum transverse cross-sectionaldimension of the distal bendable member.
 6. The instrument of claim 1wherein said grip is formed as two pieces including a grip portion and arotation knob and said grip and knob portions are supported for relativerotation therebetween.
 7. The instrument of claim 1 including means orsecuring the manually operated control handle to the grip.
 8. Theinstrument of claim 1 wherein said distal bendable member comprises aunitary slotted structure having a plurality of discs separated byslots.
 9. The instrument of claim 1 wherein said guide shaft is rigid.10. The instrument of claim 1 wherein said guide shaft is flexible. 11.The instrument of claim 1 including a plurality of proximalarticulatable members and a plurality of distal bendable members. 12.The instrument of claim 1 wherein said actuation means comprises aplurality of cables that interconnect proximal and distal members. 13.The instrument of claim 1 wherein said guide shaft has at least twolumens for respectively accommodating separate instrument shafts. 14.The instrument of claim 1 wherein said manually operated instrument hasinstrument proximal and distal bendable members.
 15. The instrument ofclaim 1 wherein said manually operated instrument has a rotation knob.16. The instrument of claim 1 wherein said manually operated instrumenthas a rigid shaft portion.
 17. The instrument of claim 1 wherein saidmanually operated instrument is supported for a sliding motion relativeto the guide member.